Perianal emergencies: Abscesses and fistulizing disease

Perianal Crohn’s disease is a challenging disease phenotype associated with abscess formation, fistulizing disease, pelvic sepsis, risk of progressive tissue destruction and impaired quality of life. Acute presentations require prompt recognition and coordinated medical and surgical management. This chapter reviews the evaluation, classification, and emergency management of perianal Crohn’s disease, with an emphasis on abscess drainage, seton placement, and the distinction between simple and complex fistulas. Adequate drainage under anesthesia remains the cornerstone of management for perianal abscesses, while seton placement may be used selectively to control sepsis and preserve future treatment options. The chapter also discusses the role and timing of biologic and immunosuppressive therapy, highlighting the importance of excluding uncontrolled pelvic sepsis before initiation or continuation of systemic treatment. Optimal care requires a multidisciplinary approach involving colorectal surgery, gastroenterology, radiology, and wound/ostomy specialists. Early intervention, accurate anatomic assessment, and staged treatment strategies are essential to reduce morbidity, preserve sphincter function, maintain quality of life and improve long-term outcomes.